EDUCATIONAL LECTURE

ACUTE CORONARY
SYNDROME
 Acute Coronary Syndrome

Definition: a group of 3 different diagnoses: UA, NSTEMI,

STEMI which share a common pathology: obstruction of
coronary arteries.
 Acute Coronary Syndrome

Definition: a group of 3 different diagnoses: UA, NSTEMI,

STEMI which share a common pathology: obstruction of
coronary arteries.

Chest pain is the most common symptom

 Acute Coronary Syndrome

Definition: a group of 3 different diagnoses: UA, NSTEMI,

STEMI which share a common pathology: obstruction of
coronary arteries.

Chest pain is the most common symptom

Chest pain caused by coronary occlusion often feels like a

sub-sternal pressure which can radiate to the left arm or
angle of the jaw.
 Chest Pain

Suspicious Chest Pain can be put into 3 different

categories
 Typical (3/3 criteria)
 Chest Pain

Suspicious Chest Pain can be put into 3 different

categories
 Typical (3/3 criteria)
 Atypical (2/3 criteria)
 Chest Pain

Suspicious Chest Pain can be put into 3 different

categories
 Typical (3/3 criteria)
 Atypical (2/3 criteria)
 Non-cardiac (1/3 criteria)
 Review Slide

The 3 Criteria are:

 Review Slide

The 3 Criteria are:

 1. the presence of substernal chest pain
 2. discomfort that was provoked by exertion or emotional
stress
 3. relieved by rest and/or nitroglycerin.
 Acute coronary syndrome

Based on ECG and cardiac enzymes, ACS is classified

into:
 STEMI: ST elevation, elevated cardiac enzymes
 Acute coronary syndrome

Based on ECG and cardiac enzymes, ACS is classified

into:
 STEMI: ST elevation, elevated cardiac enzymes
 NSTEMI: ST depression, T-wave inversion, elevated cardiac
enzymes
 Acute coronary syndrome

Based on ECG and cardiac enzymes, ACS is classified

into:
 STEMI: ST elevation, elevated cardiac enzymes
 NSTEMI: ST depression, T-wave inversion, elevated cardiac
enzymes
 Unstable Angina: Non specific or no ECG changes, normal
cardiac enzymes
 Acute coronary syndrome

The difference of
Acute Coronary Syndromes
 Unstable Anginal Chest Pain

New onset angina

 Unstable Anginal Chest Pain

New onset angina

Occurs at rest and prolonged, usually lasting >20
minutes
 Unstable Anginal Chest Pain

New onset angina

Occurs at rest and prolonged, usually lasting >20
minutes
Increasing angina: Pain that occurs more frequently,
lasts for longer periods or is increasingly limiting the
patients activity
 Unstable Angina

EKG
 May present with nonspecific ST segment changes that do not
meet criteria for NSTEMI or STEMI
 Unstable Angina

EKG
 May present with nonspecific ST segment changes that do not
meet criteria for NSTEMI or STEMI
Troponin
 normal
 NSTEMI

 EKG:
 ST depressions (0.5 mm at least) or T wave
inversions ( 1.0 mm at least) without Q waves in
2 contiguous leads with prominent R wave or
R/S ratio >1.
 NSTEMI

 EKG:
 ST depressions (0.5 mm at least) or T wave
inversions ( 1.0 mm at least) without Q waves in
2 contiguous leads with prominent R wave or
R/S ratio >1.
 Troponins:
 Elevated
 STEMI

EKG:
Q waves , ST elevations, hyper acute T waves;
followed by T wave inversions.
 STEMI

EKG:
Q waves , ST elevations, hyper acute T waves;
followed by T wave inversions.
 Troponins:
 Elevated
 STEMI ECG

 STEMI:
 Q waves , ST elevations, hyper acute T waves; followed by T wave
inversions.
 Clinically significant ST segment elevations:
 > than 1 mm (0.1 mV) in at least two anatomical contiguous leads
 or 2 mm (0.2 mV) in two contiguous precordial leads (V2 and V3)
 STEMI ECG

 STEMI:
 Q waves , ST elevations, hyper acute T waves; followed by T wave inversions.
 Clinically significant ST segment elevations:
 > than 1 mm (0.1 mV) in at least two anatomical contiguous leads
 or 2 mm (0.2 mV) in two contiguous precordial leads (V2 and V3)

 Note: LBBB and pacemakers can interfere with diagnosis of MI on EKG

 Right sided or inferior infarctions on the ECG may reflect right ventricular
dysfunction. Be careful to not decrease these patients’ preload!
 Cardiac Enzyme Details

Troponin is primarily used for diagnosing MI

because it has good sensitivity and specificity.
 CK-MB is more useful in certain situations such as post
reperfusion MI or if troponin test is not available
 Cardiac Enzyme Details

Troponin is primarily used for diagnosing MI

because it has good sensitivity and specificity.
 CK-MB is more useful in certain situations such as post
reperfusion MI or if troponin test is not available
Other conditions can cause elevation in troponin
such as renal failure or heart failure
 Cardiac Enzyme Details

Troponin is primarily used for diagnosing MI

because it has good sensitivity and specificity.
 CK-MB is more useful in certain situations such as post
reperfusion MI or if troponin test is not available
Other conditions can cause elevation in troponin
such as renal failure or heart failure
Troponins are trended every 6-8 hours until they
peak
 Management of low risk Chest Pain

EKG normal or non-specific changes with

intermediate or low risk:
 Telemetry
 Rule out ACS with 3 sets of troponins and EKG
 Consider pre-discharge stress test
NSTEMI & Unstable Angina Management

 Telemetry
 Aspirin
 Beta blocker
 Nitrates
 Heparin (UFH or LMWH)
 ACE-I/ARB
 Statin
 Antiplatelet agent: Consider ticagrelor over clopidogrel.
 When Cangrelor becomes available at UCI, this will be preferable
in many situations
 STEMI Management

STEMI patients usually go straight to the cath lab

from the ED. Goal: door to balloon 90 minutes.
Initial management for STEMI:
 Otherwise similar to NSTEMI
 Case

60 year old male with history of DM2 for 20 years,

HTN, HLD who presented to the ED with 4 hour
onset of chest pain which was described as in the
substernal chest without radiation. The pain seemed
to improve when he sits down and worsening when
he walked upstairs.
VS: T 36.9, HR: 95, BP: 84/56, RR 22, O2 sat. 99%
RA.
ECGs are shown as followed
What will you do?
 What’s your diagnosis?
 What should be done now?
 Summary

 ACS is comprised of UA, NSTEMI, and STEMIs

 Chest pain is categorized based on location and relation to
exertion
 ACS is categorized based on troponin levels and EKG

 Risk stratification for UA/NSTEMI can be done by the GRACE or

TIMI score
 ACS management medications include: Aspirin, Beta Blocker,
Nitrates, Heparin, Ace-I, Statin, an anti-platelet agent
 Door to balloon time for STEMI should be less than 90 minutes
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